Permission to Use Audio and Video Recordings

As part of our effort to share the success stories and healing experiences at The Rejuvenation Station, LLC, we often share audio and video recordings of participants in our training classes and workshops. By participating in one of these activities, you have already agreed to the terms and conditions of that participation, which include granting us permission to share your tapping segment or testimonials by audio, video or by written text with an image of you. However, we're so eager to ensure that you know how much we respect you and your privacy that we're requesting your consent and agreement for the specific content of audio, video or written testimonial identified below. To do so, please complete this form and click the submit button. Thanks!

Audio/Video Title

First Name *

Last Name *

Email Address *

I authorize the use of my name in the following format for the referenced audio and video containing my voice and/or image. *

Full Name

First Name Only

Audio and Video Recording Release

By checking the "I agree" box below and also providing my signature below, I agree to release to Jan Luther and The Rejuvenation Station, LLC, all rights to audio and/or video recordings obtained as part of my participation in a class, workshop, teleseminar, webinar or other training activity conducted by Jan Luther and The Rejuvenation Station, LLC. I understand that these recordings may be used for the purposes of teaching, training or marketing for websites operated by The Rejuvenation Station, LLC . I understand that I will receive no monetary compensation for the audio/video or for any income generated using this as marketing material. *

I agree

Please provide your signature in the box below using one of the methods listed. You can use your finger (if you have a touch screen) or mouse or click on the Type it link and type your signature into the box below. *

Clear